A lower-rib survey run end to end on a linear probe — short axis to find the rib, long axis to follow its cortex, and the costochondral junction where the picture changes — with every moment timestamped, the settings read off the device screen, and the whole recording transcribed.
About Dr. Mariz
I am Dr. Fernando Mariz, a gynecology and pelvic surgery physician practicing in New York City. Before my medical career, I served in the U.S. Marine Corps, where I developed the discipline, focus, and steadiness that continue to shape the way I care for patients today. At Maiden Lane Medical, my work covers women’s health, preventive care, sonography, pelvic pain, abnormal uterine bleeding, and minimally invasive gynecologic procedures.
About Dr. Avila
I am Dr. Jailyn Avila, an emergency medicine physician, educator, and digital health innovator based in Southern California. My clinical work is rooted in emergency care, while my teaching focuses on point-of-care ultrasound, residency education, and practical training for physicians. Through my roles with Emergent Medical Associates, UHS SoCal MEC Emergency Medicine Residency, Core Ultrasound, and FemInEM, I work at the intersection of patient care, medical education, and accessible digital learning.
Quick answer
A rib fracture shows on ultrasound as a break in the bright line of the rib cortex, and often as a fine raised stripe of lifted periosteum with a hematoma beneath it. You find both with a high-frequency linear probe placed at the point of maximum tenderness: across the rib to locate it, then along the rib to follow the cortex. It is a better first test than a chest film, and the recording puts the numbers on screen at 0:56 — ultrasonography found 58 of 59 rib fractures where the oblique rib view found 27 and the PA chest radiograph 24, in less than half the examination time. European guidance says the same thing in guideline form: when radiography is negative and clinical suspicion of an acute fracture is high, scan. What this walkthrough demonstrates is the normal, and that is precisely its value — the presenting clinician follows an intact cortex along a lower rib all the way to the costochondral junction. I would start anyone new to this exam exactly there, because you cannot recognise a step-off until you know precisely what an unbroken rail looks like at 10 MHz. Start at 4:31 for the scanning, at 0:46 for the evidence.
Looking for a device rather than the exam? The emergency medicine hub covers the models used for trauma and chest work, and the D3Ultra product page carries the full specification and current price.
Two signs
What ends the search, and what fools it
The rib cortex is a bright rail with clean shadow underneath. Two findings break that pattern for real; four normal structures break it for no reason at all. Click either sign to jump the video to the moment it is taught.
Fractures detected, of 59 confirmed in 61 patients with minor blunt chest trauma
Ultrasonography98.3%58 of 59 fracturesOblique rib view45.8%27 of 59PA chest radiography40.7%24 of 59
The study the recording displays at 0:56: Pishbin et al., Chinese Journal of Traumatology 2017. Mean examination time was 12 minutes for ultrasonography against 27 for radiography. Full citation under Sources.
the argument, the evidence and the cautionsthe rib scanned on cameraclose
No fracture is scanned on camera in this recording. The rib followed from 4:56 is intact, and the labelled picture of a fractured rib that appears at 5:41 is a reference image rather than a live acquisition — which is worth knowing before you watch, and does not cost the walkthrough anything, because the skill it teaches is recognising the normal rail. The presenting clinician also names osteophytes, erosions and pseudo-erosions among the look-alikes at 1:49; those stay in the transcript as his own words. The four listed above are the ones carried by the sources at the foot of this page.
Timestamped
Key moments, with the settings
The third column is the part normally missing from a scan video: the depth, transmit frequency and gain showing on the device at that moment. What is striking on this recording is that they never change. One depth, one frequency, one gain carry the entire survey — and that frequency is the ceiling of what this probe’s linear array offers.
| Time | What is on screen | Transducer, depth, frequency, gain |
|---|---|---|
| 0:00 | Why a rib fracture is an ultrasound problemteachingPresenting clinician to camera | |
| 0:46 | The comparison study and the EFSUMB bone recommendation, on screenteachingThe cited paper, then the recommendation list | |
| 1:29 | Where ultrasound falls short: a narrow slice, and bone you cannot reachteachingPresenting clinician to camera | |
| 2:08 | The look-alikes, and why you scan the other sideteachingPresenting clinician to camera | |
| 2:36 | Three reasons you are scanning: unknown site, localised pain, or following healingteachingLive scan of the lower ribs begins under the narration | Linear · D 40 mm · F H10.0 MHz · GN 105 dB |
| 3:02 | Scan plane: longitudinal along the rib, perpendicular to the fracture lineteachingProbe tracking along the lower ribs | Linear · D 40 mm · F H10.0 MHz · DR 80 |
| 3:57 | Cartilage against cortex, and positioning a patient who cannot moveteachingProbe tracking along the lower ribs | Linear · D 40 mm · F H10.0 MHz · DR 80 |
| 4:31 | Short axis first: the rib, its shadow, and the pleura betweenShort-axis view of the rib on the device screen | Linear · D 40 mm · F H10.0 MHz · ENH 0 · Compound OFF |
| 4:56 | Rotate to long axis and track the cortex to the costochondral junctionA continuous bright cortical line followed along the rib | Linear · D 40 mm · F H10.0 MHz · GN 105 dB · MI 0.9 |
| 5:37 | Above the cortex: hematoma and fluid lifting the periosteumLive scan, then a labelled reference image of a fractured rib | Linear · D 40 mm then 60 mm · F H10.0 MHz · DR 80 |
Settings transcribed from the device interface visible in the recording. Depth is the D value on screen; frequency is the F value, harmonic. The first four rows are argued against slides and reference images, so no device panel is on screen for them. Depth steps from 40 mm to 60 mm inside the final row.
Reading the images
What this scan shows
The rib cortex is the whole exam. Bone reflects almost all the sound that reaches it, so at 10 MHz the surface of the rib draws as a bright continuous line about a centimetre down, with nothing but acoustic shadow beneath. You are not imaging the inside of the bone and never will be. You are reading its surface, and a fracture is a break in that surface.
Find the rib in short axis first. Across the rib you get a rounded bright cap with a dark shadow falling away beneath it, and between two of those caps sits the pleural line, deeper and sliding with the breath. That is the orientation check, and it is worth repeating every so often: a bright line that is not casting a shadow is pleura, not cortex. Then rotate ninety degrees. In long axis the cortex becomes a rail you can follow, and following it is the exam — along one rib, down an intercostal space, along the next.
Two findings end the search. The first is a step or an interruption in that bright rail. The second sits above it: blood under the periosteum lifts a fine bright stripe off the bone with a dark collection between the two, and it is the sign that survives when the cortex itself looks passable. Expect the picture to change at the costochondral junction, where cartilage stops reflecting the way bone does and the sound passes into the rib instead. That transition is normal, and taking it for a break is the commonest way I see this exam go wrong.
Verbatim
Full transcript
Transcript — 6:42, 36 passages
Transcribed from the recording and edited for readability; square brackets mark an editorial clarification, and every timestamp jumps the video.
Why ultrasound, and not only radiography
0:00Today we’re going to use a Suresult D3Ultra to look for rib fractures.
0:07Now, a lot of people, a lot of doctors, when they think of a fracture, they think radiographs, they think X-rays. And even myself, I was trained that way. But in fact, ultrasound is actually much better.
0:21But wait — ultrasound, that’s soft tissue. But the cortex glows brightly, so you can see a discontinuity in the cortex. And soft tissue: you can see a hematoma underneath the periosteum. The periosteum gets lifted by, basically, fluid from the injury.
0:38So it is very, very sensitive. It’s very easy to pick up a fracture with ultrasound compared to a radiograph.
The evidence put on screen
0:46In fact, in one study specific to rib fractures — it was back in 2017 — they found that ultrasound had a sensitivity, caught 98 % of the fractures, whereas the oblique rib view and the PA chest radiographs detected 46 % and 41 % of rib fractures respectively.
1:07So that’s very, very impressive.
1:09And in fact, there’s a consensus statement that says, if you have a patient and they’ve had radiographs, but you’re like, “I still have a clinical suspicion that they have a fracture” — they say, well, get an ultrasound and satisfy your clinical suspicion. Because in general, ultrasound has a much higher sensitivity.
Where ultrasound falls short
1:28Now, the downsides of ultrasound: you have to screen through — you’re taking a very narrow slice. So you have to really screen through the bones and look all around the bones.
1:39And there’s some places you just can’t get the unit, so you can’t screen the whole body, every bone, completely — because you just can’t manipulate the ultrasound unit around every bone.
1:49The other caution is you have to make sure you’re not mistaking something like an osteophyte, or an erosion, or what’s called a pseudo-erosion, for a fracture.
1:59There’s often a little depression where a ligament attaches, and you don’t want to mistake that as a discontinuity of the cortex.
2:07And of course, children look really strange no matter what type of imaging you’re using. So you don’t want to mistake normal anatomy in a child for a fracture.
2:16And remember, you have both sides of the person, so scan both sides if you want to see a normal — and use your split screen.
2:23[This is] specific to rib fractures. If you wanted to, for example, check the lungs for pneumothorax or hemothorax, you have the right tool in your hands already. Just take 60 seconds and you can check for those as well.
Why you are scanning at all
2:36Okay. So you may have no idea where the injury is. You may have to screen through every single rib. Or you may have a clinical indication of sort of where the injury might be.
2:47And you may know exactly where the injury is, because you’re just following the injury and you’re monitoring healing.
2:52In fact, it is recommended to follow fractures with ultrasound imaging, because you can see the callus and you can basically watch it heal, if you deem that useful.
Scan plane and technique
3:02Now, for the fracture, we want an image sort of perpendicular to the fracture line. Now of course, we don’t know where the fracture is — if there is a fracture — but ideally we’ll see that discontinuity as it sort of jumps across that line.
3:14So for ribs, we know where the fracture is going to be. The fracture is going to be sort of up and down. So we’re going to go longitudinal along the rib.
3:22Now, how I’m going to do that is: I can palpate, and I can sort of feel and follow one rib — or basically follow the intercostal space, because that’s easier to follow. And then I can just basically have the transducer sort of follow just on top.
3:33And I can just follow along the rib, go down one intercostal space, follow along the rib.
3:38If you get lost, you can of course figure out where you are by taking a coronal view, or a view sort of transverse to the rib. And you can look at the ribs — because you don’t want to be looking at the pleura of the lungs and think you’re looking at the ribs.
3:50So this is a good idea: every once in a while, turn it 90 degrees and make sure you’re taking a picture of what you want.
Cartilage, and a patient who cannot move
3:57When you switch to cartilage, cartilage doesn’t look like normal bone and cortex. You can’t see through cortex, and you can see through cartilage. So it’s a striking change when you start to hit cartilage.
4:08In terms of patient positioning: if someone has a rib fracture, breathing probably isn’t very easy for them, moving around probably isn’t very easy for them. So take an image in whatever position they’re in — if they’re lying on their side, if they’re sitting, if they’re standing.
4:24Nice thing about ultrasound is you can sort of work around whatever body position they’re in, if you have a handheld ultrasound.
The rib, scanned on camera
4:31And let’s just get into it. I’ll turn it on here.
4:35And I’ll find the rib. And let’s take a short axis view.
4:44We can see where that rib is, right? It stands up in between the ribs. We have the pleura. So you don’t want to be in the pleura — you want to be the ribs, which are more superficial. But I can rotate this.
4:56So what I’m looking for is this cortex, and I want to make sure that it’s continuous. And I can follow it, and follow it, and follow it, and follow it — there it is again — and follow it, and follow it, and follow it.
5:18And then at a certain point, you’re going to hit the costochondral junction. Just double-check where you are, what’s going on.
5:25And you can see I go from not being able to see through the cortex, and then all of a sudden now I can see through the rib, right? So now I’m at cartilage instead of bone.
5:37Now remember, it isn’t just the fact that the cortex is continuous. You can also look above the cortex, right? And you’ll have basically a hematoma and fluid basically lifting up the periosteum, if there is a fracture. So keep an eye out for that as well.
Close
5:55Now if you want, you can go into a quick lung exam, but I have another video for that — or you can go to my website, [where] I think I have an hour-long video of trauma ultrasound that will explain how to do a trauma lung exam.
6:08But that’s it for the ribs.
6:09[Sponsor segment omitted, 6:09–6:42]
Hardware
Device and settings
One probe, one setting, the whole survey. The left column is the published specification; the right column is what the device interface actually showed while this exam was being run, and the right column is the one I would work from if you are reproducing it. Chest-wall work wants the linear array at the top of its frequency range, because the cortex sits a centimetre down and resolution beats penetration there. If the same probe is going to look for an effusion at the base afterwards, that is a convex-array job and these are the wrong numbers to copy.
Published specification
Suresult D3Ultra
Convex · linear · phased in one head — $2,976
- Convex3.2 / 5.0 MHz · 90–300 mm · 45°
- Linear7.5 / 10 MHz · 20 / 40 / 60 / 100 mm · 40 mm
- Phased3.2 / 5.0 MHz · 90–300 mm · 60°
- ModesB, M, Color Doppler, Power Doppler, PW Doppler
- Array192 elements · 64 channels · 256 grey levels
- Gain / DR30–105 dB · 40–110
- Body156 × 65 × 20 mm · 263 g · 2 h scanning
- PlatformiOS, Android, Windows · dual-band Wi-Fi
Read off the screen in this recording
- ArrayLinear · unchanged for the whole survey
- DepthD 40 mm · the shallowest step but one, and it steps to 60 mm at 5:58
- FrequencyF H10.0 MHz, harmonic · the top of the linear range
- GainGN 105 dB · the top of the published range
- Dynamic rangeDR 80
- ProcessingENH 0 · Compound OFF
- OutputMI 0.9 · TIS 0.2
- ModeB throughout · no M-mode or Doppler is used on this exam
Same probe, other windows
Related scans
14:09eFAST trauma exam on the same probeWhere a chest-wall survey sits inside a full trauma study — pericardium, both upper quadrants and the pelvis, scanned in one pass.Read the walkthrough →
9:28Lung exam: A-lines, B-lines and the BLUE protocolThe 60-second pleural check the presenting clinician recommends adding at 2:23, taught properly: sliding, A-lines, B-lines and the curtain sign.Watch in the Library →
1:23DVT: the three-point compression scanThe other quick linear-probe study worth knowing: common femoral, femoral and popliteal veins, compressed in sequence.Watch in the Library →All the clinical clips, filterable by anatomy and probe, are in the Scan Library.
Asked on this search
Rib fracture questions
Can you see a rib fracture on ultrasound?
Yes. The rib cortex reflects almost all the sound that reaches it, so it draws as a bright continuous line with acoustic shadow beneath; a fracture appears as a sharp discontinuity or step-off in that line. A second sign sits above the bone: bleeding lifts the periosteum away from the cortex, leaving a fine raised bright stripe with a hypoechoic collection under it. Both are found with a high-frequency linear probe placed at the point of maximum tenderness, first across the rib to locate it and then along the rib to follow the cortex. The second sign is the one I would not skip: it stays visible when the cortex itself still looks intact.
Source: ACEP Sonoguide — Musculoskeletal Ultrasound. Accessed September 5, 2026.
Is ultrasound more sensitive than an X-ray for rib fractures?
In a cross-sectional study of 61 patients with minor blunt chest trauma, ultrasonography detected 58 of the 59 rib fractures found (98.3 %), while the oblique rib view detected 27 (45.8 %) and PA chest radiography 24 (40.7 %). The ultrasound examinations also took less time, averaging 12 minutes against 27 for radiography. European guidance reflects this: EFSUMB recommends ultrasound in accessible bone areas when radiography is negative but clinical suspicion of an acute fracture is high.
Source: Pishbin E, Ahmadi K, Foogardi M, Salehi M, Seilanian Toosi F, Rahimi-Movaghar V. Comparison of ultrasonography and radiography in diagnosis of rib fractures. Chinese Journal of Traumatology 2017;20(4):226–228. Accessed September 5, 2026.
What can be mistaken for a fractured rib on ultrasound?
Several normal structures produce a discontinuity in the cortical line. At the costochondral junction a slight angulation or a narrow gap without callus is a normal variant. Tendon and ligament attachment zones, and nutrient vessels penetrating the cortex, are physiological breaks in the bone surface. In children, growth plates and accessory ossification centres read as fragments. Correlating the finding with the point of tenderness and comparing the same rib on the other side resolves most of them.
Source: Abu-Zidan FM, Alao DO, Cevik AA. Point-of-care ultrasound (POCUS) diagnosis of rib fractures. World Journal of Emergency Surgery 2025;21(1):1. Accessed September 5, 2026.
How do you scan a rib for a fracture?
Place a linear probe perpendicular to the rib for a transverse view at the site of highest tenderness, then rotate 90 degrees and trace along the length of the rib, watching the cortical line for a break and the tissue above it for a hematoma. Following the intercostal space is easier than following the rib itself, and that is the habit I would build first. Turning back to the transverse view periodically confirms you are still on rib rather than on pleura, and the patient can stay in whatever position they can tolerate.
Source: Duong HA. Cracking the Case: Rib Fractures. ACEP Sports Medicine Section, 18 July 2025. Accessed September 5, 2026.
Provenance
Sources
- Pishbin E, Ahmadi K, Foogardi M, Salehi M, Seilanian Toosi F, Rahimi-Movaghar V. Comparison of ultrasonography and radiography in diagnosis of rib fractures. Chinese Journal of Traumatology 2017;20(4):226–228Cross-sectional study of 61 patients with minor blunt chest trauma. Ultrasonography detected 58 (98.3 %) of the rib fractures, the oblique rib view 27 (45.8 %) and PA chest radiography 24 (40.7 %); mean examination time was 12 ± 3 minutes against 27 ± 6. This is the paper displayed on screen at 0:56. Accessed September 5, 2026.
- Fodor D, Rodriguez-Garcia SC, Cantisani V, et al. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound — Part I: Extraarticular Pathologies. Ultraschall in der Medizin 2022;43(1):34–57Bone recommendation 2: in accessible bone areas, when radiography is negative but clinical suspicion of acute fracture is high, US should be used (LoE 1, SoR strong; strong consensus, 95 %). This is the recommendation list shown on screen at 1:12. Accessed September 5, 2026.
- Abu-Zidan FM, Alao DO, Cevik AA. Point-of-care ultrasound (POCUS) diagnosis of rib fractures. World Journal of Emergency Surgery 2025;21(1):1Describes the step-off and the cortical interruption with acoustic shadowing, and the normal costochondral variants that resemble them; recommends correlating with the point of tenderness and comparing the contralateral side. Accessed September 5, 2026.
- Cocco G, Ricci V, Villani M, et al. Ultrasound imaging of bone fractures. Insights into Imaging 2022;13(1):189Lists the physiological bone discontinuities that mimic fractures: nutrient vessels penetrating the cortex, growth plates, accessory ossification centres, and tendon and ligament attachment zones. Accessed September 5, 2026.
- ACEP Sonoguide — Musculoskeletal UltrasoundBone cortex appears as bright hyperechoic lines with no echoes deep to the densely calcified surface; a fracture appears as a sharp discontinuity in that bright line. Accessed September 5, 2026.
- Duong HA. Cracking the Case: Rib Fractures. ACEP Sports Medicine Section, 18 July 2025Technique reference: a linear probe perpendicular to the rib for a transverse view at the site of highest tenderness, tracing the rib’s length, with a longitudinal view for confirmation; notes that the examination is operator dependent. Accessed September 5, 2026.
- Suresult D3Ultra product pagePublished specification for the device used in this recording. Accessed September 5, 2026.
- POCUS for Rib Fracture Detection — Suresult channel, 12 October 2025The recording transcribed on this page. Accessed September 5, 2026.
Which probe does your chest-wall work actually need?
A rib survey asks for the highest frequency you own and almost no depth. The lung and effusion work that usually follows it asks for the opposite. A three-in-one head covers both from one device; a dedicated pair covers both better, for more money. Tell us the setting and the case mix and you will get a direct recommendation in one conversation — one probe, two, or neither.
